Claim Benefit SpecialistPrimary Location: Pittsburgh, PA
Additional Locations: PA-Pittsburgh Apply
66610Fundamental Components: As a Claims Benefit Specialist, we strive to achieve first claim satisfaction by processing the claim correctly the first time. This also promotes customer loyalty. By doing the following we can achieve this:
- Analyzes and approves routine claims that cannot be auto adjudicated.
- Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
- Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.
- Routes and triages restricted claims to Senior Claim Benefits Specialist.
- Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.
- May facilitate training when considered topic subject matter expert.
- Learn about medical procedures.
- Learn about the different types of insurance benefit plans and understand how they are administered according to the individual plan sponsor’s contract.
- Derive satisfaction from processing member’s medical claims by resolving the issues which are preventing the claims from automatically adjudicating.
- Become eligible for bonuses and promotions based on exceptional claim processing skills, job knowledge, and proven performance.
- Experience in a production environment is a plus
- Claim processing experience is a plus.
- High School or GED equivalent.
- Medical terms are used frequently; terms are taught in training. Medical reference materials are provided.
- The job involves a consistently high volume of claims.
- Quality audits are performed.
- Extensive reference materials are provided to clarify medical procedures, changes in health care providers, claim administration and laws affecting insurance.
- Excellent organizational skills are a must.
- Processors need to be able to do several tasks at once, e.g., toggle from one screen to another for information.
- The position requires excellent attendance and punctuality.
- Processors are accountable for meeting set quality and production standards.
- Overtime may be required as business needs are identified.
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